NursingHomeGrade

Blue Lake Post Acute

991 E NEW YORK AVE, DELAND, FL 32724

Independent ratings: No payments from facilities
C

Meets federal staffing minimum — average inspection record.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
 0.58 ✓ Meets federal minimum
Health Deficiencies
Violations found during federal inspections over the last 3 years.
 16
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★★☆ (4/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
 50/100

Data last updated: April 12, 2026

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

Most recent inspection (April 8, 2025)

J Immediate jeopardy — isolated F0835 Status: Corrected

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

J Immediate jeopardy — isolated F0867 Status: Corrected

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

F Potential harm — widespread F0865 Status: Corrected

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

J Immediate jeopardy — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

J Immediate jeopardy — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

E Potential harm — pattern F0687 Status: Corrected

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 29, 2026

D Potential harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

E Potential harm — pattern F0636 Status: Corrected

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

E Potential harm — pattern F0638 Status: Corrected

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

D Potential harm — isolated F0644 Status: Corrected

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

D Potential harm — isolated F0624 Status: Corrected

Prepare residents for a safe transfer or discharge from the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2025

D Potential harm — isolated F0623 Status: Corrected

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

D Potential harm — isolated F0625 Status: Corrected

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2024

Inspection cycle 2 (August 18, 2022)

D Potential harm — isolated F0758 Status: Corrected

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2022

Inspection cycle 3 (February 24, 2022)

D Potential harm — isolated F0919 Status: Corrected

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 5, 2023

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

D Potential harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

E Potential harm — pattern F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

D Potential harm — isolated F0637 Status: Corrected

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

E Potential harm — pattern F0642 Status: Corrected

Ensure a qualified health professional conducts resident assessments.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

D Potential harm — isolated F0645 Status: Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

D Potential harm — isolated F0842 Status: Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

E Potential harm — pattern F0558 Status: Corrected

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

E Potential harm — pattern F0584 Status: Corrected

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 25, 2022

Quality Assurance & Integrity

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C

ATHENS POST ACUTE LLC

545 WEST EUCLID AVENUE, DELAND, FL 32720

64/100 score 0.72 hrs RN staffing 0 deficiencies

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